Participants in the demographic groups targeted by the social marking campaign were recruited via an online market research panel before and after each of the three bursts of the campaign (each survey wave using different participants). A burst of the campaign is defined as a process of media buying over a few weeks aimed at exposing the programme to the largest audience possible. On line data collection is used as this reduces the cost per respondent and because previous work suggests that behavioural intentions towards people with mental health problems may be better assessed using online self-complete methods rather than in-person interviews (15). Quotas were set for each type of media used to enhance the likelihood that survey participants were exposed to campaign materials. Online panel interviews were performed pre and post each of the three bursts of campaign activity. Quotas were also set to include equal distributions of age, sex, and socio-economic status and the sample was designed to be geographically representative of the population in England. Ethnic minority participants were oversampled.
Intervention: the social marketing campaign
The social marketing campaign covered by this evaluation is comprised by three bursts of multimedia activity, each lasting several weeks, with one in April of 2017 and two in February of 2018 and 2019. The campaign media targeted men and women in their mid-twenties to mid- forties in an overlapping income group, but consisting of lower social classes than in previous phases: C1: lower-middle class (Supervisory, clerical and junior managerial, administrative and professional); C2: skilled working class (Skilled manual workers); D: skilled manual occupation (Semi-skilled and unskilled manual workers); and more directly towards men, as compared to B (Intermediate managerial, administrative or professional), C1 and C2 in phases 1 and 2. In addition, activities directed at parents were introduced with the aim of facilitating open conversations, to make talking about mental health as every day and ordinary as other parent/child conversations.
The campaign included the use of social media such as Facebook, Twitter, Instagram and Snapchat; radio adverts across several stations, digital content platforms; partnership with Joe Media [a media company established in the United Kingdom (UK) in 2015 specialised in sport, politics, lifestyle and pop culture] and beer mats and washroom posters in pubs. In Time to Change phase 1 the focus was on knowledge and attitudes; during phase 2 and currently in phase 3 the focus is on behaviour change. The previous key messages of the campaign to encourage supportive contact were reworked for this target group. In the first two bursts the campaign encouraged people to ‘be in their mate’s corner’, harnessing the power of friendship and humour to reach a more detached audience. The third campaign burst developed this idea further, encouraging people to ‘ask twice’ if they feel like someone they know is acting differently. Hence, the campaign promotes empathy towards people with a mental health problem as a key mediator of the effect of contact on prejudice (16) while encouraging people to maintain direct contact (17)(as opposed to social distancing). In the process, the advertising provides parasocial (virtual) contact (17) and promotes imagined contact (18). For parents a specific section with parent information was included in the Time To Change website; and short films were used in public relations and social media. This clear call to action provides the target audience with practical advice about starting a conversation, something for which there is evidence in terms of suicide prevention (19).
Mental health-related knowledge was measured by the Mental Health Knowledge Schedule (MAKS) (20). The MAKS comprises six items covering stigma-related mental health knowledge areas (20): help seeking, recognition, support, employment, treatment, and recover, and six items that enquire about classification of various conditions as mental illnesses (21). Each item is scored on a 5-point Likert scale, from 5 = ‘strongly agree’ to 1 = ‘strongly disagree’. The total score is calculated by adding together the response values of each item, and a higher score indicated greater knowledge.
Attitudes towards mental illness were assessed based on the 12 version item of the Community Attitudes toward the Mentally Ill Scale (CAMI)(22), previously used in Time To Change campaign evaluation (12) and in the Health Survey for England (23). Each item is scored on a 5-point Likert scale, from 5 = ‘strongly agree’ to 1 = ‘strongly disagree’. The total score is calculated by adding together each single item, and higher score indicates more positive attitudes.
Desire for Social Distance
The desire for social distance (the level of intended future contact with people with mental health problems) was measured by the Intended Behaviour subscale of the Reported and Intended Behaviour Scale (RIBS) (24). The RIBS consist of four domains (living with, working with, living nearby, and continuing a relationship with someone with a mental health problem) and assesses reported and the intended behaviour in each domain. In this study, only intended behaviour was evaluated. Each item is scored on a 5-point Likert scale, from 1 = ‘strongly disagree to engage in the stated behaviour’ to 5 = ‘strongly agree with engaging in the stated behaviour’. The total score is calculated by adding together each single item, and higher score indicated higher willingness to engage in the behaviour.
Prompted campaign awareness was assessed for each type of media and / or activity used by Time to Change. Individuals who reported seeing any of the advertisements were categorised as ‘campaign aware’ while those who responded ‘no’ or ‘don’t know’ were categorised as ‘not campaign aware’. Campaign awareness associated with the post-burst stage pertains to awareness of the specific media activity immediately preceding the survey, while awareness during the pre-stage refers to the recall of the media used in the previous campaign burst.
The assessment of the first pre stage used materials from phase 2 of Time to Change, and as awareness as assessed at each point comprises unprompted awareness as well as prompted awareness (i.e. using materials from the last campaign) it includes awareness of any previous TTC activity. There were no other campaigns to reduce stigma or increase mental health literacy during this period as the only other such campaign, Heads Together, had finished before the first burst of phase 3.
Social contact with someone with a mental health problem was assessed by asking the following question: Who is the person closest to you who has or has had some kind of mental health problem? Scoring the answers in the following categories: self, immediate family (spouse/sister/brother/parents…), one of your children, partner (living with you), partner (not living with you), other family (uncle/aunt/cousin/grandparent…), friend, acquaintance, work colleague, neighbours, ex-partner, no-one known. For more simplicity in the analysis the categories were reduced to three: no-one-known, self, other.
All analyses were weighted to reflect population characteristics in England. Survey weights were developed using prevalence rates of ethnicity with geographic region from the UK Government’s Office for National Statistics. All models were adjusted for the impact of the ‘‘Burst’’ as well as main relevant socio-demographic characteristics identified from the literature in the field [i.e., gender; age; ethnicity; socioeconomic group; geographic region; marital status; having children; working status; degree of familiarity with mental illness (Categorized as me/other/no-one-known answering the question: Who is the person closest to you who has or has had some mental illness?).
Descriptive statistics for participant demographics were calculated and presented using unweighted frequency and weighted percentage/mean/standard deviation.
Adjusted logistic regression models were used to analyse campaign awareness. To examine whether there was a consistent pre/post effect, we included a variable indicating whether the assessment occurred before or after the burst of media (pre vs. post). We also investigated factors significantly associated with campaign awareness where the following independent variables were entered into the model: ethnicity (categorical: White, Asian, Black, Mixed or Other), gender, age (categorical: 25-29, 30-34, 35-39, 40-45), marital status (married: yes/no), having children (children: yes/no) employment status (categorical: employed (full or part-time employment), not working (unemployed or retired), student), socioeconomic group (categorical: lower middle class C1, skilled working class C2, semi-skilled and unskilled manual workers D), geographic region (categorical: Yorkshire and Humber, North East, North West, East Midlands, West Midlands, East of England, London, South East, South West) and social contact (categorical: having a mental health problem oneself, knowing someone with a mental health problem or not knowing anyone with a mental health problem).
Multivariable linear regression models were used to analyse the total MAKS, CAMI and RIBS scores. A pre/post effect for each outcome measure was investigated as described above. Multivariable logistic regression models estimated the odds of responding positively (i.e., agree strongly or agree slightly) to each of the MAKS and RIBS items. All items were coded so that agreement summarised a less stigmatising response. Presence of a long-term trend was examined by including campaign burst as a covariate in the model for the total score of MAKS, CAMI and RIBS, and for each item of the MAKS and RIBS scales.
The relationship between each of the outcome measures (CAMI, MAKS, RIBS) with campaign awareness was assessed by including the campaign awareness variable into the adjusted linear regression model. This will also inform us of factors associated with each outcome measure.